Regístrese
Buscar en
Enfermedades Infecciosas y Microbiología Clínica
Toda la web
Inicio Enfermedades Infecciosas y Microbiología Clínica Abdominal violaceous skin lesions of a 47-year-old woman following a geometric p...
Información de la revista
Vol. 36. Núm. 9.
Páginas 598-599 (Noviembre 2018)
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Visitas
415
Vol. 36. Núm. 9.
Páginas 598-599 (Noviembre 2018)
Diagnosis at first sight
DOI: 10.1016/j.eimc.2017.10.005
Acceso a texto completo
Abdominal violaceous skin lesions of a 47-year-old woman following a geometric pattern
Lesiones cutáneas violáceas en el abdomen de una mujer de 47 años siguiendo una distribución geométrica
Visitas
415
Andrea Combalia
Autor para correspondencia
andreacombalia@gmail.com

Corresponding author.
, Daniel Morgado-Carrasco, Xavier Fustà-Novell, Jose M. Mascaró-Galy
Servicio de Dermatología, Hospital Clínic, Barcelona, Spain
Este artículo ha recibido
415
Visitas
Información del artículo
Texto completo
Bibliografía
Descargar PDF
Estadísticas
Figuras (2)
Tablas (1)
Table 1. Drug susceptibility testing assay: antibiogram and minimal inhibitory concentration (μg/ml).
Texto completo
Case report

We present the case of an obese 47-year-old woman from the Dominican Republic, living in Spain since 2003. She came to our outpatient department reporting a 15-day-history of painful nodules and ulcerations on the abdomen that had been treated by her general practitioner with amoxicilin/clavulanate 875/125mg t.i.d. for 7 days with no improvement. She mentioned that 8 weeks previously, during a vacation trip to her country, she had undergone a mesotherapy session with injections of a liquid formula containing phosphatidylcholine to reduce the fat from her abdomen.

On physical examination redness, swelling, drainage and ulceration were seen at the sites of mesotherapy injection (Fig. 1). Ultrasound imaging revealed subcutaneous edema, but no signs of deep abscessification, and MRI (T2) showed fat necrosis at the sites of injection. A punch biopsy was performed. Histopathologic examination revealed only mild dermoepidermal edema and a mixed infiltrate on the dermis without granulomas (Fig. 2). Periodic-Acid Schiff (PAS) and silver staining were negative as well as Ziehl-Neelsen. Mycobacterium abscessus was identified on skin cultures. Antibiogram is shown in Table 1.

Fig. 1.

Redness, swelling, drainage and ulceration at the sites of mesotherapy injection.

(0,08MB).
Fig. 2.

Histopathologic examination revealed only mild dermoepidermal edema and a mixed infiltrate on the dermis without granulomas.

(0,22MB).
Table 1.

Drug susceptibility testing assay: antibiogram and minimal inhibitory concentration (μg/ml).

Antibiotic  MIC (μg/ml) 
Amikacin  S (16) 
Amoxiciline/Clavulananate  R (>64) 
Cefepime  R (>32) 
Cefoxitin  R (64) 
Ceftriaxone  R (>64) 
Ciprofloxacin  R (34) 
Clarithromycin  S (0.5) 
Cotrimoxazole  R (>8) 
Doxycycline  R (>16) 
Imipenem  R (32) 
Linezolid  R (32) 
Minocycline  R (>8) 
Moxifloxacin  R (8) 
Tigecycline  S (0.25) 
Tobramycin  R (8) 
Outcome

The patient began treatment with doxycycline 100mg b.i.d and clarithromycin 500mg b.i.d for 2 months. Although identification of Mycobacterium abscessus subspecies was not provided, drug susceptibility testing assay showed a pattern of multidrug resistance except for clarithromycin. Therefore, doxycycline was stopped, and clarithromycin was administered 1g b.i.d during the following 4 months. The patient completed a six-month course of antibiotics with complete resolution of the swelling, drainage and ulceration, but the lesions resolved with hypertrophic scars. Some of the scars were surgically excised to get a better esthetic result and to discard the possibility of persisting infection. Cultures and PCR for mycobacterium of the samples were negative, confirming the cure of the infection.

Commentary

Mesotherapy is a treatment involving local subcutaneous injections of minute quantities of various substances for cosmetic purposes (non-steroidal anti-inflammatory medications, enzymes, nutrients, antibiotics, hormones, vitamins or plant extracts). Mesotherapy may be used to aid weight loss in conjunction with dietary modification, hormone replacement therapy, exercise and nutritional supplements. Both infectious and noninfectious complications of mesotherapy have been described previously. However, injection-site infections with non-tuberculous mycobacteria are often reported.

Mycobacterium abscessus is an atypical fast-growing mycobacterium, ubiquitous in the environment that can be found in water, soil and dust. Several outbreaks of M. abscessus skin and soft tissue infections have been reported1 mostly associated with medical procedures,2 cosmetic surgery,3 acupuncture and tattoos.4

The skin infection typically presents as nodules, recurrent abscesses or non-healing ulcers. Multiple lesions may be observed at the same time.5 The diagnosis is confirmed by positive cultures from drainage material, surgical debridement or skin biopsy. However, the isolation of M. abscessus is very difficult. Therefore, PCR, a rapid diagnostic method that allows both diagnosis and species identification, can be performed. Differential diagnosis is broad and bacterial and fungal infections, granulomatous and tumoral diseases must be ruled out.5,6 However, mycobacterium infection secondary to mesotherapy must be suspected when lesions appear in a geometrical pattern or match the sites of mesotherapy injections.

Infections due to M. abscessus are difficult to treat because these mycobacteria are intrinsically resistant not only to the classic anti-tuberculous drugs, but also to most of the antibiotics that are currently available.6,7M. abscessus can be divided into at least three subspecies: M. abscessus abscessus, M. abscessus massiliense, and M. abscessus bolletii which is rarely isolated. The 2 major subspecies, M. abscessus abscessus and M. abscessus massiliense, have different erm(41) gene patterns, which provides M. abscessus abscessus intrinsic resistance to macrolides. For this reason, an individualized therapeutic approach, based on a combination of minimum 2 antibiotics is usually recommended. Surgical management of atypical mycobacterial is sometimes required.8,9

To minimize the risk of infectious complications from mesotherapy, providers should adhere to recommended standard precautions, and follow safe-injection practices with appropriate aseptic techniques, although there are currently no FDA-approved injectable drugs for fat elimination.

References
[1]
A.B. Wentworth, L.A. Drage, N.L. Wengenack, J.W. Wilson, C.M. Lohse.
Increased incidence of cutaneous nontuberculous mycobacterial infection, 1980 to 2009: a population-based study.
Mayo Clin Proc, 88 (2013), pp. 38-45
[2]
G. Rodríguez, M. Ortegón, D. Camargo, L.C. Orozco.
Iatrogenic Mycobacterium abscessus infection: histopathology of 71 patients.
Br J Dermatol, 137 (1997), pp. 214-218
[3]
M.I. Newman, A.E. Camberos, J. Ascherman.
Mycobacteria abscessus outbreak in US patients linked to offshore surgicenter.
Ann Plast Surg, 55 (2005), pp. 107-110
discussion 110
[4]
R.R. Falsey, M.H. Kinzer, S. Hurst, A. Kalus, P.S. Pottinger, J.S. Duchin, et al.
Cutaneous inoculation of nontuberculous mycobacteria during professional tattooing: a case series and epidemiologic study.
Clin Infect Dis, 57 (2013), pp. e143-e147
[5]
D.Z. Uslan, T.J. Kowalski, N.L. Wengenack, A. Virk, J.W. Wilson.
Skin and soft tissue infections due to rapidly growing mycobacteria: comparison of clinical features, treatment, and susceptibility.
Arch Dermatol, 142 (2006), pp. 1287-1292
[6]
R. Nessar, E. Cambau, J.M. Reyrat, A. Murray, B. Gicquel.
Mycobacterium abscessus: a new antibiotic nightmare.
J Antimicrob Chemother, 67 (2012), pp. 810-818
[7]
K.A. Nash, B.A. Brown-Elliott, R.J. Wallace.
A novel gene, erm(41), confers inducible macrolide resistance to clinical isolates of Mycobacterium abscessus but is absent from Mycobacterium chelonae.
Antimicrob Agents Chemother, 53 (2009), pp. 1367-1376
[8]
W. Rappaport, G. Dunington, L. Norton, D. Ladin, E. Peterson, J. Ballard.
The surgical management of atypical mycobacterial soft-tissue infections.
Surgery, 108 (1990), pp. 36-39
[9]
W.J. Plaus, G. Hermann.
The surgical management of superficial infections caused by atypical mycobacteria.
Surgery, 110 (1991), pp. 99-103
Copyright © 2017. Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica
Opciones de artículo
Herramientas
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

es en pt
Política de cookies Cookies policy Política de cookies
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.